Abstract
Objective To determine whether patients with TIA or ischemic stroke with coexisting cardiovascular disease (i.e., history of coronary or peripheral artery disease) are still at high risk of recurrent ischemic events despite current secondary prevention guidelines.
Methods In a population-based study in Oxfordshire, UK (Oxford Vascular Study), we studied consecutive patients with TIA or ischemic stroke for 2002–2014. Patients were treated according to current secondary prevention guidelines and we determined risks of coronary events, recurrent ischemic stroke, and major bleeding stratified by the presence of coexisting cardiovascular disease.
Results Among 2,555 patients (9,148 patient-years of follow-up), those (n = 640; 25.0%) with coexisting cardiovascular disease (449 coronary only; 103 peripheral only; 88 both) were at higher 10-year risk of coronary events than those without (22.8%, 95% confidence interval 17.4–27.9; vs 7.1%, 5.3–8.8; p < 0.001; age- and sex-adjusted hazard ratio [HR] 3.07, 2.24–4.21) and of recurrent ischemic stroke (31.5%, 25.1–37.4; vs 23.4%, 20.5–26.2; p = 0.0049; age- and sex-adjusted HR 1.23, 0.99–1.53), despite similar rates of use of antithrombotic and lipid-lowering medication. However, in patients with noncardioembolic TIA/stroke, risk of extracranial bleeds was also higher in those with coexisting cardiovascular disease, particularly in patients aged <75 years (8.1%, 2.8–13.0; vs 3.4%, 1.6–5.3; p = 0.0050; age- and sex-adjusted HR 2.71, 1.16–6.30), although risk of intracerebral hemorrhage was not increased (age- and sex-adjusted HR 0.36, 0.04–2.99).
Conclusions As in older studies, patients with TIA/stroke with coexisting cardiovascular disease remain at high risk of recurrent ischemic events despite current management. More intensive lipid-lowering might therefore be justified, but benefit from increased antithrombotic treatment might be offset by the higher risk of extracranial bleeding.
Glossary
- DWI=
- diffusion-weighted imaging;
- HR=
- hazard ratio;
- LDL=
- low-density lipoprotein;
- MI=
- myocardial infarction;
- N-STEMI=
- non-ST-elevation;
- OXVASC=
- Oxford Vascular Study;
- PCSK-9=
- proprotein convertase subtilisin/kexin type 9;
- STEMI=
- ST-elevation;
- TOAST=
- Trial of Org 10172 in Acute Stroke Treatment
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
The Article Processing Charge was funded by Wellcome Trust.
OXVASC study coinvestigators are listed in appendix 2 at the end of the article.
- Received October 4, 2018.
- Accepted in final form March 21, 2019.
- Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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